Letter to the editor: Outcomes of pregnancy in autoimmune hepatitis: A population‐based study
Authors: Anees Ahmad, Hamood Ur Rehman Chaudhry
Journal: Hepatology (2022)

To the editor, A recent publication by Wang et al.[1] titled "Outcomes of pregnancy in autoimmune hepatitis: A population‐based study" piques our curiosity. The authors' efforts are significant and should be acknowledged by the readers. The last point made by the author is that pregnancy rates among women with autoimmune hepatitis (AIH) have remained consistent in recent years, even though AIH is associated with significant maternal and perinatal risks such as gestational diabetes, hypertensive problems, and premature birth. Whether these risks are modified by corticosteroid use or AIH disease activity, further research is needed to establish a low risk of postpartum hemorrhage and good maternal and newborn survival. However, we acknowledge the study's shortcomings, yet some other ways may improve and strengthen the study's conclusions. The retrospective study has raised various concerns because of the likelihood of recall bias and inadequate medical documentation that could have been addressed if the authors had included current cases. Second, significant details about pregnancies and immunosuppressive regimes in AIH patients who carried their pregnancies above 20 weeks' gestation were not documented. A study by Heneghan et al.[2] included information on immunosuppression regimes such as the number of patients utilizing azathioprine and prednisolone and the number of pregnancies and age at diagnosis and age at conception. Because patients who are sensitive to azathioprine typically develop adverse effects to the medicine during the first few months of starting treatments, it may be advisable to achieve remission using steroid monotherapy in de novo manifestations of AIH throughout pregnancy. Women are predisposed to autoimmune disease, as previously recognized; nevertheless, data on changes in the maternal immune system during pregnancy were also insufficient. Similarly, one study found B and T cell counts; T and NK cell activities; IgG, IgM, IgA levels; antibody‐dependent cellular cytotoxicity; and complements.[3] Pregnancy is linked to immune system changes in the mother. Despite these modifications, the clinical course of AIH and fetal outcomes are favorable.[3] Also, the authors also failed to report significant causes of recurrent miscarriages and their diagnostic workup. According to one study, two miscarriages occurred in a patient during the evaluation of repeated abortions, and a positive result for antiphospholipid antibodies was discovered. The link between antiphospholipid antibodies and AIH is frequently found particularly during pregnancy.[4] The incidence of maternal hemorrhage increases in the presence of portal hypertension and esophageal varices. Conception in these people correlates with a higher than usual loss rate, stillbirth, and premature birth. Pregnancies with AIH have good fetal outcomes comparable with other autoimmune illnesses.[3,4] In patients with AIH, favorable perinatal outcomes are possible. However, strict observation by a competent interdisciplinary team is required to allow for diagnosis and management of AIH flares. CONFLICT OF INTEREST Nothing to report.